• It is important to be clear about the definition of counselling and the methodological issues in assessment of its efficacy
• Reviews and meta-analyses of counselling for general psychopathology up to the mid-1990s were notpartic8larly favourable
• More recent reviews of the effectiveness of counselling have been much more positive. In general these reviews have been more rigorous in the inclusion criteria for entry of trials into the meta-analyses
• Research has been able to demonstrate the fundamental importance of the therapeutic relationship. A sound therapeutic relationship provides an avenue to communicate respect, understanding, warmth, acceptance, commitment to change and a corrective interpersonal experience
• The process of counselling, general counsellor therapeutic competence, the attributes of counsellors, and the organisation within which they work, rather than necessarily the method of counselling, have all been shown to affect outcome
• Staff morale, training and resources are key determinants of outcome Therapist quality and consistency, supported by their preparation and training, is probably as important in terms of outcome as treatment modality
A clear, credible intervention delivered with explicit quality control will maximize treatment compliance
Employing adequately trained, qualified, and supervised counsellors is crucial; ongoing supervision is optimised via video-taping, with the tapes being used during weekly supervision to minimize “therapeutic drift”
Systematic, protocol driven, manualised interventions improve outcome;
outcomes are optimised by the use of standardised, manual based treatment protocols, delivered by therapists with a high degree of supervision and training
• A number of studies demonstrate the efficacy of generic counselling in methadone maintenance programmes
• Targeted counselling has been shown to be an effective intervention with multi-substance use, particularly among cocaine and alcohol misusers
• There is both effectiveness and cost-effectiveness evidence supporting the use of motivational interviewing, skills-based cognitive interventions, community reinforcement programmes, and behavioural marital therapy There is broad support in the literature for the effectiveness for cognitive psychotherapeutic interventions for drug users; Such cognitive
interventions should be used for those groups who have more severe psychopathology and/or dependence
It appears that cognitive interventions are differentially effective across different classes of drugs, with evidence for the effectiveness of CBT with opiate-users
Motivational interviewing is effective, particularly for those drug and alcohol users who are in the contemplation stage of the process of change
12 step interventions are particularly effective when used as an aftercare resource. Any positive effect of 12 step intervention is additive, not independent
Project MATCH found that 12-step Facilitation, Cognitive Behaviour coping skills, and Motivational Enhancement Therapy were equally highly
effective. Therapist training, quality and consistency were vital components of the positive outcomes delivered by Project MATCH
• More structured and organised interventions such as motivational
interviewing, skills-based cognitive interventions, community reinforcement programmes, behavioural marital therapy, Alcoholics Anonymous and 12 Step approaches all seem to work somewhat better that do less structured approaches
Evidence indicates the utility of brief interventions in communicating and implementing harm reduction strategies, but they are not so useful for more complex clients with additional psychological/psychiatric issues, clients with severe dependence, clients with poor literacy skills, or clients with difficulties related to cognitive impairment
While brief intervention can result in significant gains at minimum cost, generalist workers conducting brief interventions will not replace the need for specialist alcohol and other drug treatment
Family and friends need to be treated as clients in their own right, although they can also be treated as an adjunct to an individual’s treatment.
Involving family members can draw substance misusers into treatment and ensure that changes impact on the whole system. The types of family intervention with the best evidence to date are systemic, behavioural, unilateral, community-reinforcement and social network approaches Confrontational counselling, psychoanalytic psychotherapy and educational talks and lectures have been seen to be of little use in promoting positive outcomes amongst alcohol misusers
Psychosocial inputs are not a ‘quick fix’, and often the added benefits of counselling are only evident after some months
• In any review of treatment it must be clear that drug dependence is not necessarily an idiographic, psychological deficit. There is no doubt that patients’ long term access to good quality social and community support and non-drug using networks will influence the trajectory of dependence Dependence can be seen as a functional way of relating to one’s
environment which means that treatment should be tailored not only to individual needs, but also mapped onto the context in which the individual finds him or herself: all treatment, including counselling, has to consider the wider context of people’s lives
Two key predictors of outcome and long term success are cognitive ones:
one is self-efficacy; the other is baseline motivation or readiness to change
• High quality supervision from well-trained supervisors is vital
Supervision has a number of characteristics and functions. It is formal, regular, and provides an opportunity for the counsellor to develop and explore their skills and understanding, their self-awareness, and issues and difficulties in their practice as counsellors as they arise
Supervision also provides protection for the client and the agency by monitoring the counsellor’s work
The majority of alcohol and drug treatment clients have multiple issues which can combine to create a complex case. Accordingly, care planning and management is vital: a clearly developed care plan should form the basis of all interventions
Case management is particularly useful in alcohol and other drug
treatment, as clients generally present with a myriad of issues that need to be addressed
• Setting goals is an important aspect of care planning and case management
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